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Clinical Article

Hospital Discharge Education


for Patients With Heart Failure:
What Really Works and
What Is the Evidence?
Sara Paul, RN, MSN, FNP

D
espite advances in mates, 54% of readmissions may be
therapy, morbidity preventable, and inadequate dis-
and mortality remain charge planning and education or
high in patients hos- lack of patient follow-up are common
pitalized for heart factors in readmission.3-5 Lack of
PRIME POINTS failure. Although new approaches compliance with medications, fail-
to improving the use of guideline- ure to follow a salt-restricted diet,
recommended evidence-based and delays in seeking medical atten-
• Educating patients therapies at hospital discharge are tion are among the primary reasons
before discharge
undeniably needed,1 truly compre- for the high rate of rehospitalization
promotes self-care,
hensive and competent care for among patients with heart failure.6
reduces readmissions, patients hospitalized with heart fail- Patients who are not knowledge-
and helps patients spot ure requires a strong focus on edu- able about their disease and their
problems early. cation of patients and their families. medication are at a severe disadvan-
Education at discharge is a vital tage. In one study,7 the association
• Patients should be component of improving outcomes of medication adherence and knowl-
active partners in the in heart failure. The institution of a edge was tested in 61 patients age
management of their structured system of patient and 50 years or older who had heart
health. family education that involves a failure. Patients’ knowledge of the
multidisciplinary team and empha- dosage, frequency, and indication
• Patients should sizes medication adherence, sodium
and fluid restrictions, and recogni-
of each of their heart failure medica-
learn about their tions and patients’ ability to open
conditions and medi- tion of signs and symptoms that medication bottles, read labels, and
indicate progression of disease may distinguish tablet/capsule colors
cations and when to
be as important as ensuring that were assessed. Lower medication
seek medical treatment.
patients are prescribed appropriate adherence (P = .001) and an inabil-
medical therapy. Specific topics of ity to read labels (P = .002) were
• Nurses need to instruction for patients hospitalized significantly associated with an
understand the barri- with heart failure are listed in Table 1. increased number of cardiovascular-
ers to self-care and Poor adherence to these instructions related visits to the emergency
help patients overcome can lead to worsening of disease and department. Patients with greater
these barriers. rehospitalization. According to esti- medication adherence had a mean

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recognize the importance of educa-
Table 1 Lifestyle changes required in the self-management of heart failurea
tion and recommend that patients
Adopt a low-sodium diet (<3000 mg for NYHA functional class I and II; <2000 mg for
NYHA functional class III and IV) receive educational materials as part
Restrict fluid intake to 2 L (approximately 8 cups) per day if indicated
of the patients’ complete discharge
Stop smoking
instructions.8 These materials should
address recommended activity level,
Increase activity/exercise at a low to moderate intensity
diet, discharge medications, follow-
Monitor weight daily
up appointment, weight monitoring,
Notify health care provider of signs and symptoms of worsening heart failure, such as
weight gain of more than 3 lb (1.3 kg) in a week or 2 lb (0.9 kg) overnight
and what to do if signs or symptoms
Eliminate alcohol consumption
worsen.2,8,9
The American College of Cardi-
Reduce fat and cholesterol in diet if coronary artery disease is present
ology/American Heart Association
Learn all signs and symptoms to report to health care provider: pain in jaw, neck, or
chest; increased shortness of breath or fatigue; dizziness or syncope; swelling in feet, (ACC/AHA) Clinical Performance
ankles, legs, or abdomen; palpitations; and racing heart (>120 beats per minute) Measures for Adults With Chronic
Abbreviation: NYHA, New York Heart Association. Heart Failure9 include the following
a Based on data from Albert and Paul.2
inpatient performance measures
for patients with heart failure: dis-
(standard deviation) of 0.22 (0.73) Performance Measures charge instructions, evaluation of
visits to the emergency department Related to Discharge left ventricular systolic function,
per patient compared with patients Education for Patients angiotensin-converting enzyme
who were less adherent, who had With Heart Failure inhibitor or angiotensin-receptor
1.00 (2.47) visits per patient. Over- Performance measures are crite- blocker for left ventricular systolic
all, greater knowledge of, skills with, ria used by organizations to deter- dysfunction, adult smoking cessation
and adherence to medication were mine whether an organization is advice/counseling, and anticoagu-
associated with fewer visits. fulfilling its vision and meeting its lant at discharge for patients with
Education of patients at discharge patient-focused goals. These meas- atrial fibrillation. The guidelines
promotes self-care, reduces readmis- ures are standardized to evaluate recommend that the clinical care
sions, and helps patients identify hospitals and health care systems, team collect data and review com-
problems early, increasing the chances regardless of location, in order to pliance with these measures on a
for intervention and improved out- promote positive outcomes in patient routine basis, look for changes, and
comes. In this article, I discuss the care. Performance measures may adjust practice patterns as neces-
importance of educating patients reflect medical management of sary to improve performance. The
and their families in preventing patients, but they may also assess performance measure of discharge
rehospitalization for heart failure. I aspects of patient care, such as edu- instructions and its components are
also address the use of performance cation of patients and their families shown in Figure 1.9
measures to improve patients’ out- at discharge. The latest guidelines The Joint Commission evaluates
comes and methods for promoting for management of heart failure from 4 performance measures for patients
retention of discharge instructions. the Heart Failure Society of America with heart failure that are similar to
those of the ACC/AHA: discharge
instructions (HF-1), assessment of
Author left ventricular function (HF-2), use
Sara Paul is a nurse practitioner at Western Piedmont Heart Centers in Hickory, North of angiotensin-converting enzyme
Carolina. She manages patients with heart failure and runs the heart failure program/
clinic. inhibitors in patients with left ven-
tricular systolic dysfunction (HF-3),
Corresponding author: Sara Paul, RN, MSN, FNP, Heart Function Clinic, Western Piedmont Heart Centers, 1771
Tate Blvd SE, Ste 201, Hickory, NC (e-mail: smcpaul@earthlink.net). and smoking cessation counseling
To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656.
(HF-4). These Joint Commission
Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints@aacn.org. core measures require that patients

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4. Discharge Instructions
Heart failure patients discharged home with written instructions or educational material given to the patient or care giver at discharge
or during the hospital stay addressing all of the following: activity level, diet, discharge medications, follow-up appointment,
weight monitoring, and what to do if symptoms worsen
Numerator Heart failure patients with documentation that they or their caregivers were given written discharge
instructions or other educational material addressing all of the following:
1. Activity level
2. Diet
3. Discharge medications
4. Follow-up appointment
5. Weight monitoring
6. What to do if symptoms worsen
Denominator Heart failure patients discharged home.
Included populations:
• Discharges with an ICD-9-CM Principal Diagnosis Code for heart failure as defined in table 3
• A discharge to home or home care
Excluded populations:
• Patients less than 18 years of age
Period of assessment Hospital discharge
Sources of data Administrative data and medical records
Rationale
Education of heart failure patients and their families is critical. Failure of these patients to comply with physician’s and other health care
providers’ instruction is sometimes a cause of HF exacerbation. A significant cause of patient’s failure to comply is lack of understand-
ing. It is, therefore, incumbent on health care professionals to be certain that patients and their families have an understanding of the
causes of heart failure, prognosis, therapy, dietary restrictions, activity, importance of compliance, and the signs and symptoms of
recurrent heart failure. Throrough discharge planning is associated with improved patient outcomes (11).
Reference Recommendation(s)
CMS/JCAHO Core Measure: Heart Failure, HF-1: Discharge Instructions (9).
Method of Reporting
Aggregate rate (standard error) generated from count data reported as a proportion.

Figure 1 American College of Cardiology/American Heart Association performance measure: discharge instructions.
Abbreviations: CMS, Centers for Medicare and Medicaid Services; HF, heart failure; ICD-9-CM, International Classification of Disease, Ninth Revision, Clinical Modifi-
cation; JCAHO, Joint Commission.
Reprinted with permission from ACC/AHA Clinical Performance Measures for Adults With Chronic Heart Failure: A Report of the American College of Cardiol-
ogy/American Heart Association Task Force on Performance Measures (Writing Committee to Develop Heart Failure Clinical Performance Measures)
Endorsed by the Heart Failure Society of America.
©2005, American Heart Association, Inc.

with heart failure receive written reviewed to determine the percentage Diet: 70% (range, 58%-94%)
instructions or educational material of patients who receive the quality of Exercise: 61% (range, 26%-81%)
at discharge that will adequately care indicators derived from the clini- Smoking cessation: 14% (range,
address all of the components cal practice guidelines of the Agency 0%-33%)
mentioned in the guidelines.10 The for Health Care Policy and Research. The variability of counseling
intention is that through use of A total of 1623 hospitalizations for between hospitals was high, and
these performance measures, the heart failure were reviewed; the mean documentation may not reflect what
quality of cardiovascular care will frequencies of documentation of was actually practiced.12 The docu-
be improved.11 However, conformity counseling about medications, mentation may or may not have
with these indicators among health weight, diet, exercise, and smoking reflected the extent of the counsel-
care providers is not guaranteed. cessation were as follows: ing. How the information was con-
In 1997, medical records from Medications: 97% (range, 95%-98%) veyed and the depth of the patient’s
9 hospitals were retrospectively Weight: 6% (range, 3%-12%) understanding of the information

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were not documented. More recently, reduce hospital stays and improve whether receipt of this measure was
data from 81 142 admissions of functional status.15 However, these predictive of other elements of dis-
patients with heart failure in the programs often involve outpatient charge planning. Credit for the core
Acute Decompensated Heart Failure programs, such as clinics or home measure (HF-1) was not given unless
National Registry (ADHERE) were visits, that are beyond those nor- all 6 components (activity level, diet,
analyzed to determine rates of con- mally assessed in the ACC/AHA discharge medications, follow-up
formity with the 4 core performance performance measure on discharge appointment, weight monitoring,
measures from the Joint Commis- instructions. It is unclear whether and what to do if signs or symptoms
sion.13 The median rate of conform- the discharge instruction perform- worsen) were documented. Despite
ity with discharge instructions (HF-1) ance measure as recorded in the recommendations that complete
was only 24% (range, 0%-99%), and hospital reflects whether the patients instructions be given to patients with
the median rate of conformity with did or did not receive each defined heart failure before hospital discharge,
HF-4 (counseling for smoking ces- component of education. Patient both the process intervention tools to
sation) was 43.2% (range, 0%-100%). education may be documented in facilitate HF-1 and HF-1 itself were
A substantial gap in overall perform- the medical record even if the edu- underused. Delivery of the full set of
ance is apparent among hospitals. cation was cursory and allowed little HF-1 components was significantly
The establishment of educational time for the patient to absorb and more likely in the 46% of patients who
initiatives and quality improvement retain the information.15 Conversely, received process improvement tools.17
systems to reduce this variability many patients and their families are Additional measures and/or better
may substantially improve care. not ready to learn at the time of methods for identifying and validat-
diagnosis, regardless of how thorough ing performance measures related to
Does Compliance With the instructional session may be. heart failure may be needed to
Performance Measures Extensive education may be better improve care and outcomes of
Improve Clinical Outcomes? absorbed when a patient is in a sta- patients with heart failure.14
The relationship between current ble condition and has adapted to Data suggest that in practice,
ACC/AHA performance measures living with heart failure.16 discharge education is not empha-
for patients hospitalized with heart In the analysis of data from sized as an essential component of
failure and clinical outcomes was OPTIMIZE-HF, the discharge instruc- optimal care for patients with heart
investigated in the Organized Pro- tion performance measure did not failure. A retrospective review18 of
gram to Initiate Lifesaving Treatment have an effect on mortality or rehos- medical records at a large, inner-city
in Hospitalized Patients With Heart pitalization at 60- to 90-day follow- teaching hospital of 104 patients
Failure (OPTIMIZE-HF), a registry up.14 Fonarow et al14 concluded that with heart failure showed that dis-
and performance improvement current performance measures charge counseling about medication
program for patients hospitalized related to heart failure, other than adherence, restricted sodium intake,
with heart failure. Only use of an the prescription of an angiotensin- and the importance of weight moni-
angiotensin-converting enzyme converting enzyme inhibitor or an toring was provided to only 50%,
inhibitor or an angiotensin-recep- angiotensin-receptor blocker at dis- 48%, and 9% of patients, respectively.
tor blocker at discharge was associ- charge, have little effect on patients’ The large number of patients who
ated with a reduction in mortality outcomes shortly after discharge. are discharged without receiving
or rehospitalization at 60 to 90 days Another OPTIMIZE-HF analysis17 education may represent important
after discharge.14 Trials comparing specifically addressed education of missed opportunities to decrease
conventional management of heart patients; researchers assessed the morbidity and mortality.
failure with management programs characteristics of patients who did
that included counseling of patients and did not receive the full set of Educational Tools and a
about diet, exercise, medications, components from the Joint Com- Multidisciplinary Team
and monitoring have shown that mission process-of-care performance Critical pathways and in-hospital
disease management programs can measure (HF-1) and then analyzed instructional tools may improve the

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provision and quality of discharge education materials. Use of the ded- were 4 times higher in the group
education. The AHA Get With the icated heart failure team led to quick of patients who received usual care
Guidelines heart failure program is and sustained improvements.21 (n=77) than in patients in the inter-
a hospital-based quality improve- In addition to verbal information, vention group. Additionally, patients
ment program implemented in 2001 a combination of educational mate- in the control group required nearly
to promote the use of up-to-date rials may enhance a patient’s ability 50% more skilled nursing care visits
guidelines for treating patients with to absorb information. Books, and more than twice as many home
heart disease and stroke. Currently, newsletters, videos, CDs, Web pages, health aid visits than did the patients
more than 1300 hospitals are enrolled and computer-based programs aug- in the intervention group. The 6-week
in the program.19 A key component ment the learning process and offer cost savings for the intervention
is the Patient Management Tool, a further opportunities for education group was $67 804.
Web-based interactive assessment at patients’ convenience after dis-
and reporting system that tracks charge from the hospital. Many Barriers to Learning
treatment and facilitates evidence- patients will need repeated education Successful management of heart
based medicine. This tool helps through follow-up telephone calls, failure often requires major lifestyle
caregivers manage patients’ care by newsletters, educational bulletins, adjustments, such as modifications
providing (1) drop-down reminders or support groups because of the in diet and activities, compliance
of current guidelines at key data volume of information that is given with a complex medication regimen,
points, (2) prescriptive medication at the time of hospital discharge. and the need to assess and monitor
reminders specific to the patient’s Educational tools must be a com- signs and symptoms. Despite best
disease, (3) printed disease-specific ponent of multidisciplinary care efforts at education, helping patients
patient education materials before provided to heart failure patients.22 understand all of the complexities
discharge, and (4) automated patient The team approach to education of of their disease and therapy may be
dismissal notes and referring patients improves patients’ outcomes. difficult. Many patients have low
physician letters.20 An example of In one study,23 an intervention group levels of knowledge of their disease
the discharge instructions is shown (n=44) of patients received educa- and lack a clear understanding of
in Figure 2.19 This tool includes tion from a cardiac nurse educator, heart failure and self-care. In a study24
education as part of the overall a registered dietitian, and a physical of knowledge level in patients with
discharge checklist. therapist, along with corresponding heart failure, although two-thirds
Although many hospitals are written materials. These patients of the patients reported receiving
adapting the tools from the Get With received an initial visit, as well as a information or advice about self-care
the Guidelines heart failure program follow-up visit from the nurse edu- from health care providers, 37% of
into care, the presence of tools alone cator, dietitian, and physical therapist patients knew “a little or nothing,”
is not enough to guarantee evidence- during the patients’ hospitalization. 49% knew “some,” and only 14%
based practices. In a study21 of how Discharge planning was coordinated knew “a lot” about heart failure.
core measures from the Joint Com- with home health nurses, who rein- Approximately 40% of the patients
mission are applied at a university forced the instructions given in the did not recognize the importance of
hospital, availability of standardized hospital. Patients in the control group weighing themselves daily, and 25%
order forms, computer discharge who received “usual care” did not did not appreciate the risk of con-
instructions, and education materi- have access to the nurse educator, suming alcohol. Although 80% of the
als did not lead to improvement in did not automatically receive dietary patients knew they should limit the
scores for core measures. The scores and physical therapy consultations, amount of salt in their diet, only one-
improved only after the appointment did not have routine telephone con- third regularly avoided salty foods.
of a dedicated heart failure physician tact after discharge, and did not Understanding patients’ barriers
and nurse practitioner who used receive home visits from nurses to learning may enable nurses to
the standardized forms, computer trained in management of heart tailor educational approaches accord-
discharge instructions, and the failure. Hospital readmission rates ingly. Simply communicating a

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CARDIOVASCULAR DISEASE DISCHARGE INSTRUCTIONS
Discharge Medications Dosage Frequency Start Date/Time
- Nitroglycerin
- Aspirin 81 mg
- ACE-I/ARB
- Beta-Blocker
- Statin
- Clopidogrel
- Spironolactone

- Pain

Exercise/Activity/Diet/Prescription Information Given: See back for health education and resources
If you smoke, STOP! (Smoking will make heart disease worse and may cause death.)
☐ Booklet Given, see back ☐ Does not smoke - or - Has not smoked in more than 12 months
☐ AMI/CHF Discharge Packet Given ☐ Home Exercise Program Instruction Provided
☐ Drug info/food/drug interaction info provided ☐ Cardiac Rehab Information Provided
☐ Daily Weights Instructions Given-See back Cardiac Rehab Ordered ☐ Yes ☐ No
☐ Diet __ Low Sodium, Low Cholesterol, high fiber Your Total Cholesterol: ___
☐ Resources on back reviewed ☐ Driving Instructions Given
May Return to Work on (date) ___________________ ☐ Activity: Light activity until follow-up appointment
Follow-Up appointment:
___________ Dr.: ___________________________ Phone: ___________________________________ Date: ___________

___________ Dr.: ___________________________ Phone: ___________________________________ Date: ___________

Home Care Agency: _______________________________ Phone: ___________________________________ Date: ___________

MD/RN Signature _________________________________________________________________________ Date ______________

Choices Provided on ______________________________ :CM Signature ________________________________ Date __________

I have received a copy of this form and understand the instructions. Patient signature ______________________________________

NOTE: Any old, unused pills or liquid at home should be flushed down the toilet. Please discuss with your doctor any medications
(including over the counter pills or liquid not ordered by the doctor) you have been taking at home if they are not listed above.
KEEP THIS FORM AND BRING IT WITH YOU TO ALL FOLLOW-UP DOCTOR APPOINTMENTS

Figure 2 The American Heart Association Get With the Guidelines heart failure discharge tool.19
Abbreviations: ACE-I, angiotensin-converting enzyme inhibitor; AMI, acute myocardial infarction; ARB, angiotensin-receptor blocker; CHF, congestive heart failure; CM,
case manager; info, information; MD, physician; rehab, rehabilitation; RN, registered nurse.

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therapeutic plan is different from for patients of different cultures, and of the admissions. One-third of the
successfully educating patients and flexibility should be given to allow patients were noncompliant with
their families. Patients and their patients to maintain their cultural medications, diet, or both. In a study29
families should be treated as partners differences yet remain within healthy of 220 patients with multiple hospi-
in learning, not as pupils. If patients parameters. If possible, a dietitian tal admissions, the rates of noncom-
feel engaged in the discussion and should be involved to help patients pliance with medication, smoking
their learning needs are assessed, select foods that are acceptable to the cessation, and abstaining from alco-
they may feel that the information patients’ palate but low in sodium. hol were as high as 64%, 69.5%, and
is more pertinent to their situation. Foods such as soy sauce or tomato 71%, respectively. Compliance may
Teaching sessions should not be a salsa are high in sodium, and every be increased by improving patients’
1-way communication session, but effort should be made to find low- understanding of the importance
should engage patients in identifying sodium substitutes. of the therapy and by streamlining
their learning needs.25 Nurses who Educational interventions should therapy through the use of once-
teach patients should receive training be specifically tailored for patients daily agents to reduce the complex-
to ensure that the educational infor- and their families and should target ity of pill-taking regimens.30
mation taught is consistent among their particular barriers to learning,
all staff members. If the information such as functional and cognitive Cognitive Impairment
varies among the staff, patients and limitations, misconceptions, low A patient’s ability to understand,
their families can become confused. motivation, and low self-esteem.25 remember, and apply what he or she
Hospitalized patients may be The reasons for difficulty in follow- was taught at discharge is another
anxious about their disease and may ing a prescribed regimen are multi- large barrier. Elderly patients often
be concerned about their ability to factorial, but possible barriers to have comorbid conditions in addi-
perform self-care once they are home. self-care and optimal adherence may tion to heart failure that can make it
Plenty of time should be allowed for include a complex medication regi- difficult to understand and comply
patients to ask questions as they men that is confusing to the patient, with therapy. The incidence of cog-
digest the new information. Paper cognitive impairment that makes it nitive impairment among patients
and pencil should be available at the difficult for the patient to remember more than 65 years old who have
bedside for patients to write down instructions, or the lack of motiva- heart failure is high compared with
questions as they think of them. tion to follow discharge instructions. the incidence in younger patients,31
Patients and family members should indicating that education of elderly
be given a telephone number that Complex Medication persons is a challenge. Cognitive
they may call to speak to a nurse if Regimen impairment may include short- or
they have any questions or problems Patients with heart failure are long-term memory loss, dementia,
after discharge. Knowing that they often discharged with complex or attention deficit. In a study of
will receive follow-up home visits or medication regimens.26 Despite the recall of recommendations and adher-
telephone calls may allay their anxi- best intentions of practitioners, ence to advice among patients with
ety and fears and allow patients to patients’ understanding of the rea- heart disease, Kravitz et al32 found
absorb information more readily. son for each medication may be that patients who did not recall the
An articulate and fluent transla- low, and their ability to follow ther- instructions had a much greater risk
tor should be included in teaching apeutic instructions may be limited. of noncompliance with medications
sessions when patients do not have Noncompliance can be as high as and diet than did patients who
command of the English language. 64% for medication and 22% for remembered the instructions. Inter-
The translator should be available diet.27 In a retrospective study28 of estingly, patients whose physicians
if a patient has questions later. Cul- 1031 admissions for heart failure, counseled them about lifestyle
tural differences may impede the noncompliance with medications changes and medications were sig-
learning process. Dietary prefer- and diet led to sodium retention nificantly (P<.05) more likely to
ences may be somewhat different and was the causative factor in 55% recall the recommendations during

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a follow-up telephone interview. health nurse, or physical therapist not necessarily accompanied by
Unfortunately, even among patients to clarify changes in medication. Any concomitant changes in compliance
who recalled the advice, the non- health care professional who has behaviors. Poor physical capacity,
compliance rate with smoking ces- regular contact with a patient can fatigue, and depression and anxiety
sation remained high. help in evaluating whether the patient are common among patients with
Cline et al33 examined the extent is taking the medications correctly. heart failure,25 and all these factors
of noncompliance with prescribed A list of medications and when can lead to lack of motivation and
medication in elderly patients with to take them should be in large print, low interest in learning how to per-
heart failure and reviewed the and patients should be instructed to form self-care. Ni et al24 reported
extent to which patients recalled place that list prominently in the area that although most elderly patients
information given about it. All where daily medications are stored. with heart failure confirmed the
patients received standardized ver- Weekly pill containers with 3 com- importance of restricting sodium
bal and written information about partments per day for morning, intake and limiting fluid consump-
their medication, but only 12 (55%) afternoon, and night doses help tion, less than half reported always
could correctly name what medica- patients remember if they have taken avoiding salty food, and an equally
tion had been prescribed, 11 (50%) their medications earlier in the day. low percentage did not closely mon-
were unable to report the doses Refrigerator magnets with informa- itor daily weight or fluid intake. This
prescribed, and 14 (64%) could not tion about signs and symptoms of type of noncompliance indicates the
remember what time(s) the med- worsening heart failure and the need for education about the impor-
ication was to be taken. telephone number that the patient tance of dietary restrictions and
To overcome memory issues, we should call if those symptoms occur potential consequences of nonad-
must ensure that all instructions can serve as easily accessible daily herence. Effective communication
and advice verbally communicated reminders. Pictures of foods to avoid, between patients, their families, and
to patients are also provided in a such as high-sodium foods, should the health care team may help mini-
written format that patients can be available for patients to keep near mize the difficulties associated with
take with them to share with family the patients’ grocery shopping list. dietary restrictions.
members and refer to later. Family Follow-up telephone calls or home Health care providers may think
members should be included in the visits may help patients remember that a broad statement such as
educational session so that they hear and follow important discharge “remove salt from your diet” or
the information and can reinforce instructions. Charts that specify the “weigh yourself every day” is suffi-
the instructions once the patient is time of day for each medication dose, cient education. But important
at home. If the patient’s friend or either with the use of a clock depict- aspects of communication are left
family member who assists in ing the time or with doses scheduled out of instructions like these, such
preparing the weekly medications around meals, may enhance patients’ as why the change is important, spe-
cannot attend a teaching session or ability to take pills at the correct cific details, and examples of how to
an appointment when medication time of day (Figure 3). Pictures of go about these lifestyle changes.2
changes are discussed, a note explain- each pill, which can be found in many The poor taste of low-sodium food
ing the changes should be sent home medication books or online, can help may also be a large barrier.34 Elicit-
with the patient. Even better, a tele- patients identify their medications ing the assistance of a clinical dieti-
phone call to the person who over- and may reduce medication errors. tian for strategies that help patients
sees the patient’s medications will and caregivers find special food items,
prevent confusion or medication Lack of Motivation plan menus, adjust recipes, and
errors. If a patient with cognitive Patients’ difficulty in following alter the preparation of food can be
impairment does not have a family recommendations for diet, exercise, of great benefit.2,35 Helping a patient
member to assist with medications, and smoking cessation may be due plan meals and prepare a grocery
it may be helpful to contact the to lack of motivation and/or self- list with appropriate low-sodium
patient’s local pharmacist, home control. An increase in knowledge is foods will offer “real-life” ideas and

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PATIENT MEDICATION CHART
Heart Failure Clinic

Patient’s name:

Date Medication Dosage

Figure 3 Patient medication chart with clock.

suggestions. Cookbooks and Web assist them.36 Education and coun- Results of studies24,37 on alcohol use
sites with low-sodium recipes can be seling sessions to promote behavior among patients with heart failure
helpful to patients and their spouses change, referral to smoking cessation indicate that 25% to 40% of patients
as they plan meals (Table 2). Lists of programs, and recommendations to with heart failure do not understand
foods to avoid, foods to enjoy in use nicotine replacement substances the risks of alcohol consumption.
moderation, and foods that are may be key to helping patients with Efforts to educate patients about the
within dietary guidelines should be nicotine addiction. Medications detrimental effects of alcohol on
readily available for patients, along that promote smoking cessation, cardiac function should be reinforced,
with lists of substitutes or alterna- such as bupropion or varenicline, and resources should be provided
tives to high-sodium foods. should be used with extreme caution, that can facilitate alcohol-withdrawal
Although smoking can contribute and patients
to increased risk for multiple hospi- should be
tal admissions, most patients lack closely moni- Table 2 Web sites offering low sodium recipes and food
suggestions
motivation to stop smoking ciga- tored during
www.lowsaltfoods.com
rettes.29 Despite medical counseling therapy.
and awareness that smoking induces Similar www.alsosalt.com/lowsodiumfoods.html

signs and symptoms of heart failure, techniques http://yourtotalhealth.ivillage.com/hungry-girl-low-sodium-food.html


patients who have been hospitalized should be used www.dinewise.com/low_sodium
often continue to smoke. Although in patients who http://www.americanheart.org/presenter.jhtml?identifier=572
smokers may be instructed to quit, are at risk for www.hfsa.org/pdf/module2.pdf
they may not be provided with the continuing to http://www.hy-vee.com/health/health.asp
proper counseling or referral to a consume alcohol www.drugs.com/cg/2-gram-sodium-diet.html
program or technique that would after discharge.

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efforts. Support group therapy and level, and motivation.25 Next, the Researchers in one study49 showed
alcohol cessation programs may offer patient’s learning needs and barriers that an educational intervention
support to patients who find it diffi- to learning must be determined. The including written materials specifi-
cult to stop consuming alcohol. third step includes discussion with cally directed at patients with low
Motivation for making behavioral the patient to plan the educational literacy (less than ninth-grade liter-
lifestyle changes may be low in intervention and set goals. In the acy level) and supportive phone calls
patients who are not ready to com- fourth step, the education and infor- was associated with improvements
mit to making those changes. Despite mation is delivered to the patient in self-care behaviors and signs and
education on lifestyle changes that and the patient’s family as planned. symptoms related to heart failure.
are necessary when living with heart The last step includes evaluation of
failure, many patients are not ready the learning process. Strategies that One-on-One Sessions
to learn how to manage their illness. fit with the patient’s learning styles, One-on-one sessions between a
Some patients are more prepared cognitive level, and motivation by nurse or multidisciplinary team
than others to hear the information using tailored interventions offer a member and a patient are an impor-
and make the appropriate lifestyle directed way to enhance compliance tant component of education at dis-
changes. For that reason, it is impor- among patients.6,7,23,25-27,29,30,34,40-45 Prac- charge. In a trial50 of 223 patients
tant to determine each patient’s tical ideas for improving patients’ with heart failure, researchers com-
level of readiness to make lifestyle adherence are listed in Table 3. pared the effects of a 1-hour, one-on-
changes and then individualize the Nurses are crucial to the success of one teaching session with a trained
educational sessions to the patient’s education and can increase the nurse educator with the effects of
level of readiness.38,39 For instance, if probability of optimal discharge the standard discharge teaching
a patient states that he or she does instruction and better outcomes by done by the staff. Patients in the
not wish to follow a low-sodium using better education strategies.23 education group also received a copy
diet, simply handing the patient of the treatment guidelines for heart
written information on that topic Written Materials failure written in nonmedical, patient-
may have limited benefit. However, Patients with heart failure recog- friendly language. Patients receiving
exploring patients’ dietary prefer- nize the importance of discharge the educational intervention had a
ences with them and tailoring recipes education. When asked about what 35% lower risk of rehospitalization
and spice suggestions may offer information is important, patients or death. The intervention patients
appealing ideas to patients. If a ranked information on medication also reported increased self-care
patient enjoys foods cooked with and signs and symptoms as most practices. Compared with controls,
garlic salt, perhaps a combination important, followed by general edu- they were more likely to weigh
of garlic powder and onion powder cation about heart failure, risk factors, themselves daily (66% of intervention
will be pleasing to the patient. prognosis, activity, psychological patients vs 51% of controls, P=.02),
Patients should be encouraged to factors, and diet.46-48 The method of follow a sodium-restricted diet (32%
experiment with low-sodium spices teaching patients varies from patient vs 20%, P = .05), and stop smoking
that suit their personal tastes. to patient, depending on multiple (97% vs 90%, P = .03).50
factors. Patients’ educational level A prospective, randomized trial51
Methods of Discharge dictates their ability to comprehend was conducted to determine the effect
Instruction written information, and poor of a formal education and support
The methods and delivery of visual acuity limits the benefit of intervention on 1-year readmission
patient education are varied and written materials. Language barriers or mortality and costs of care for
may be important to outcomes. must be considered in non–English- patients hospitalized with heart fail-
Education of patients consists of 5 speaking communities. All printed ure. The intervention consisted of
steps, beginning with assessment material must be written at an appro- an experienced cardiac nurse con-
of a patient’s knowledge, learning priate reading level that will meet ducting an hour-long session cover-
abilities, learning styles, cognitive the needs of a wide variety of patients. ing each patient’s knowledge of the

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Table 3 Key strategies for providers and patients for improving education and involvement/adherence of patients
Strategy Evidence or rationale supporting strategy Practical implementation
Provider led
Nurse- or pharmacist-led disease Readmission rates for heart failure significantly Initiate or increase current involvement
management interventions decreased when a cardiac nurse educator was used to in a multidisciplinary program
coordinate an inpatient heart failure education program
with comprehensive discharge planning23
90 days after discharge, multidisciplinary intervention
reduced all-cause admissions by 44% compared with
usual care; heart failure admissions decreased by 56%40
In-hospital initiation of At 60 days, 91.2% of patients started on β-blockers Assess patient’s knowledge of medications
medication before discharge remained on therapy, compared with before discharge
73.4% who started taking the drugs after discharge41 Provide prescriptions for medications at
discharge
Improvement in communication Improved communication with patients with heart failure Confirm that patient has been fully
between provider and patient before discharge resulted in a 16% reduction in mor- informed about medication before dis-
about medication tality, 14% decrease in readmissions, and 31% charge
decrease in heart failure–related rehospitalization, with Provide written educational material
1 life saved for 34 patients treated42
Reduction in the complexity of Patients on once-daily therapy had significantly greater Consider once-daily therapy and/or use
drug regimens adherence than did patients on twice-daily therapy43 of polypharmacy if appropriate
Combination medications can increase adherence44
Avoidance of medications with Adverse effects can decrease quality of life and prevent Provide patient with a list of possible
known adverse effects patients from adhering to treatment with some adverse effects from medications;
agents30 include discussion of sexual dysfunc-
tion as a potential adverse effect
Discussion of adherence during In 39% of encounters, providers did not ask patients Confirm that patient has been fully
normal follow-up care about the medications patients are taking45 informed about medication at follow-up
Heightened awareness of the Education level, insurance, socioeconomic status, Note patient-specific barriers or special
possibility of poor adherence advanced age, cognitive impairment, and depression circumstances
may be predictive of poor adherence30
Awareness of limitations: vision, Use of larger text and pictures, a mild exercise plan, Tailor education method and/or material
hearing, mobility, and cognition slower teaching pace, increased repetition of informa- to the individual patient’s needs or
(memory) tion, and involvement of family can lessen the impact limitations
of patients’ limitations25
Awareness of low motivation A nonthreatening climate, positive feedback, and a trust- Provide more context about why the
(evaluation of fatigue and ing relationship between health care provider and patient’s heart failure plan is important
depression) and low self-esteem patient can improve a patient’s self-esteem25 Encourage treatment of fatigue and
depression
Use of multiple educational Patients with heart failure are often discharged with Provide written material, brochures,
materials complex treatment regimens26 booklets, newsletters, videos, CDs,
and Web-based programs to increase
patient’s exposure to material about
heart failure
Use of multidisciplinary A team approach to patient education can reduce hospital Include dietitian, respiratory therapist,
involvement readmission rates and costs22 physical therapist, pharmacist, and
social worker in discussions
Patient led
Active participation in disease Lack of adherence to medications, failure to follow a Advise patients to write down questions
management salt-restricted diet, and delays in seeking medical in order to remember them and ask
attention are primary reasons for the high rate of when the physician or nurse is present
rehospitalization among patients with heart Suggest that patients attend support
failure6 groups or teaching sessions, read all
literature that is provided, and watch
all CDs or videos
Continued

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Table 3 Continued

Strategy Evidence or rationale supporting strategy Practical implementation


Patient led
Overcoming a reluctance to tell Noncompliance with medication and diet can be as high Encourage patients to be open and
provider about adherence as 64% and 22%, respectively27 honest in all discussions with health
problem Noncompliance rates with smoking cessation and care providers
abstaining from alcohol can be as high as 69.5% and
71%, respectively29
Understanding basic aspects of Greater medication knowledge, skills, and adherence are Encourage patients to ask health care
disease associated with fewer visits to the emergency depart- providers to explain the disease and its
ment7 consequences, and to ask for referral
to other educational sources (eg, Web
site) for more information
Understanding complex dosing Strategies to improve dosing schedules include the use Provide patients with a take-home med-
schedules of pill boxes to organize daily doses, asking the physi- ication chart showing timing of dose
cian if the regimen can be simplified, and cues to and photograph of tablets
remind patients to take medications30
Need for family support Educational interventions involving patients and their family Suggest that patients bring family mem-
members can be effective in improving adherence30 bers to follow-up and share care plans
with them

illness, the relation between medica- daily life) both in the hospital and 1 (t=4.9, P<.001) but not in the con-
tions and illness, the relationship week after discharge. In addition to trol group (t=1.9, P=.06).
between health behaviors and ill- evidence-based education such as
ness, early signs and symptoms of recognition of warning signs and Social Support
worsening heart failure, and when symptoms of worsening heart fail- Support from people close to a
and where to obtain assistance. ure, problems of individual patients patient with heart failure is often
Patients’ understanding of the top- such as social interaction, sexual important to success. For example,
ics was assessed and reviewed to function, and limited access to the patients who are married tend to
provide information about gaps in general practitioner were discussed. have a greater knowledge about their
patients’ knowledge for the nurse to During the hospital stay, the study disease.24 The self-management of
address. In subsequent follow-up nurse assessed each patient’s needs, dietary restrictions is difficult and
sessions (by telemonitoring), the provided education and support to usually occurs within the context of
nurse reviewed knowledge and the patient (and the patient’s fam- family; therefore, a family education
provided support for patients to ily), gave the patient a card listing intervention was tested for the effect
reinforce the initial educational the warning signs and symptoms, on improving self-management
foundation, theoretically by and discussed discharge. Within 1 related to sodium intake.53 Patients
empowering patients and offering week after discharge, the study with heart failure and a family
strategies to improve adherence. nurse telephoned the patient to member received either (1) in-depth
The intervention was associated assess potential problems and rein- education and counseling (in both
with a 39% decrease in the total forced and continued education as verbal and written form, a video on
number of readmissions.51 warranted. One month after dis- heart failure care, and individualized
In another study,52 179 patients charge, patients from the interven- dietary discussion and feedback to
with heart failure were randomized tion group reported complying with promote knowledge as well as self-
either to usual care or to a nurse 14 of the 19 self-care behaviors, vs efficacy in selecting and preparing
education initiative (consisting of 12 behaviors for the control group. low-sodium foods) by a nurse expert
intensive, systematic, and planned The increase in self-care behavior and a dietitian or (2) the same in-
education by a study nurse about from baseline to 9 months was sig- depth education, counseling, and
the consequences of heart failure in nificant in the intervention group feedback by the same research nurse

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and dietician plus 2 additional ses- continuing, and completing a behav- of a disease management program
sions focused on enhancing family ioral change,” the intervention was that combined discharge planning,
support and patients’ choice through partially successful; patients were education, optimization of therapy,
communication and empathy. Self- able to choose and begin a change improved communication, early
reported dietary sodium intake and strategy but did not follow through attention to signs and symptoms,
24-hour urinary levels of sodium, a in continuing and completing the and intensive follow-up. After 2
reflection of dietary sodium intake, strategies. Readiness to change behav- years, all-cause death and hospital
were measured at baseline and 3 ior and perceived control should be admissions for heart failure were
months after the intervention. considered for future studies to 36% lower in the intervention group
Both groups had decreases in examine how these factors influence than in the usual-care group. Com-
dietary sodium intake and sodium learning, motivation, and behavioral pared with baseline, patients in the
level in the urine at 3 months; how- change. Research with a motivational intervention group reported signifi-
ever, the group with the additional model may facilitate behavioral cant improvements in functional
2 sessions that focused on family change and improve the quality of status, quality of life, and rate of
support had greater decreases in the life of patients with heart failure. prescription of β-blockers.
levels of sodium in the urine (mean Telephone monitoring is a pos-
[standard deviation], 3438 [1205] mg Education of Patients sible tool to reinforce education
decreased to 2612 [1255] mg in the After Discharge and assess patients’ status. Remote
intervention group vs 2945 [1606] mg Follow-up after hospitalization titration of the dose of β-blocker
decreased to 2932 [1747] mg in the can reinforce the education that was carvedilol by advanced practice
control group) and had a greater per- delivered at discharge. In a study55 of nurses was studied in patients with
centage of those with 15% decreases home-based care after discharge, the heart failure.58 Before therapy, the
in levels of sodium in the urine (67.9% intervention involved a nurse visit- nurses instructed patients about the
of intervention patients vs 40.7% of ing the patient once at home after side effects of β-blockers, how to
control patients, P=.04). discharge to teach the patient about take a pulse, and monitoring weight.
heart failure and the medications. A Three times a week, patients reported
Motivation reduction in heart failure events (38 their weights, vital signs, and symp-
A motivational intervention is vs 51; P=.04) and unplanned read- toms to the nurses by phone. The
one that increases the likelihood of missions (68 vs 118; P=.03) was seen advanced practice nurses counseled,
a person choosing, continuing, and in those patients receiving the follow- educated, and reminded patients to
completing a change strategy. A up visit at home compared with the increase the dose of carvedilol every
behavioral management interven- control group.55 In a study56 of 106 2 weeks until the target dose was
tion was designed to augment usual patients assigned to either follow-up reached. As a result of this interven-
care and to help patients with heart at a nurse-led heart failure clinic or tion, 96% of patients reached a ther-
failure establish healthier behaviors usual care, fewer patients in the apeutic dose (6.25 mg twice daily),
to improve their quality of life.54 intervention group than in the con- and 71% of patients reached target
Two advanced practice nurses trol group died or had to be admitted doses of 25 mg twice weekly in
facilitated the intervention, which to the hospital after 12 months (29 approximately 8 weeks. No hospital-
included group classes and individ- vs 40; P=.03). All patients answered izations for heart failure occurred
ual follow-up with telephone calls. a questionnaire after 3 and 12 months during this period.58 Another study59
The intervention was evaluated by to evaluate their self-care behaviors, included 14 randomized controlled
receiving feedback from the partici- and the intervention group scored trials (4264 patients) of remote
pants about their satisfaction and significantly higher than the control monitoring (telemonitoring and/or
anecdotal information from the class group did (P=.02 after 3 months structured telephone support) to
leaders. Patients reported high satis- and P=.01 after 12 months).56 determine if such monitoring
faction with the intervention. When In another study,57 researchers improved outcomes in patients with
motivation was defined as “choosing, assessed the long-term effectiveness heart failure. Remote monitoring

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programs reduced the rates of hos- experienced cardiac nurse educator specialists contribute significantly
pital admissions related to heart who coordinated a targeted education to improving outcomes. In a review
failure by 21% and the rate of all- program for inpatients with heart of 29 trials of multidisciplinary
cause mortality by 20%. New tech- failure coupled with comprehensive management programs, McAlister
nologies such as telemonitoring can discharge planning and immediate et al61 found that 1 of the 3 elements
be helpful tools to improve educa- outpatient reinforcement through a crucial to a successful program is
tion but should be used as an addi- coordinated nurse-managed home the use of nurses who are knowl-
tion to a comprehensive educational health care program. After 30 to 60 edgeable about heart failure.
discharge program. days, the readmission rate for heart Providing comprehensive dis-
failure in the usual-care group was 6 charge education to patients with
Comprehensive Approach times the rate in the intervention heart failure is essential to improv-
Although they may have been group. After 6 months, the readmis- ing outcomes, and cardiac nurses
focused on a single tactical method, sion rate in the usual-care group are in a position to take on the role
most of the studies mentioned was nearly 4 times the rate in the of educators. Patients with heart
investigated the value of a compre- intervention group (44.2% vs 11.4%; failure should understand their con-
hensive educational program that P=.01). dition, their medications, and when
included a combination of inpatient In another study60 of 165 hospi- to seek medical treatment. As more
and outpatient education. The more talized patients with heart failure is learned about the important effects
comprehensive an educational strat- who were randomized to either a of education and self-care on patients’
egy is, the better. For instance, in comprehensive nurse intervention outcomes, the need to move away
one study40 patients with heart fail- or usual care, the nurse intervention from the traditional view of patients
ure were randomized to receive either included educating patients about as passive recipients of information
usual care or a nurse-directed, multi- the disease and its treatment, includ- is clear. Patients should be viewed
disciplinary intervention that ing training in how to adjust dosages as active partners in the manage-
included a review of patients’ condi- of diuretics, as well as home visits, ment of their health.
tions and their medications, home telephone contact, extensive monitor- Cardiac nurses play a funda-
visits, dietary advice, and telephone ing of each patient, and up-titration mental role in the educational
calls. At follow-up 90 days after of medication. Patients in the nurse process and can be the primary
discharge, the multidisciplinary intervention group had fewer all- practitioners who teach and evalu-
intervention had reduced all-cause cause admissions than did patients ate patients’ self-care abilities,
admissions by 44% (P = .02) com- in the control group (86 vs 114, P= which include weight monitoring,
pared with usual care, and admis- .02), had fewer admissions for heart sodium and fluid restrictions, phys-
sions for heart failure were reduced failure (19 vs 45, P<.001), and spent ical activities, regular medication
by 56% (P = .04). significantly fewer days in the hospi- use, monitoring signs and symp-
In a study23 of the potential ben- tal for heart failure (mean, 3.43 days toms of disease worsening, and
efits of comprehensive management vs 7.46 days, P = .005). early search for medical care. Car-
of elderly patients with heart failure, diac nurses should strive to under-
the intervention consisted of an Summary stand the barriers to patient
Although much of the literature adherence and self-care and learn
has been devoted to programs to strategies to educate patients to


improve the process of care, less overcome those barriers. A dis-
d t attention has been paid to the com-
prehensive strategies provided by
charge management program led
by a cardiac nurse that incorporates
To learn more about providing care for
patients with heart failure, read “Evidence- specially trained nurses that have the latest evidence, guidelines, and
Based Nursing Care for Patients With Heart improved outcomes for patients with tools can substantially improve the
Failure” by Nancy Albert in AACN Advanced
Critical Care, 2006;17(2):170-183. Available at heart failure. When studied in the level of care for patients with heart
http://www.aacnclinicalissues.com. context of multidisciplinary teams, failure. CCN

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care for elderly patients hospitalized with
eLetters heart failure. Arch Intern Med. 1997;157(19):
Now that you’ve read the article, create or con- 2242-2247.
tribute to an online discussion about this topic 13. Fonarow GC, Yancy CW, Heywood JT.
using eLetters. Just visit http://ccn.aacnjournals Adherence to heart failure quality-of-care
.org and click “Respond to This Article” in either
the full-text or PDF view of the article.
indicators in US hospitals: analysis of the
ADHERE Registry. Arch Intern Med. 2005;
165(13):1469-1477.
Financial Disclosures 14. Fonarow GC, Abraham WT, Albert NM, et al.
None reported. Association between performance measures
and clinical outcomes for patients hospital-
ized with heart failure. JAMA. 2007;297(1):
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82 CRITICALCARENURSE Vol 28, No. 2, APRIL 2008 http://ccn.aacnjournals.org

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Hospital Discharge Education for Patients With Heart Failure: What Really Works and
What Is the Evidence?
Sara Paul
Crit Care Nurse 2008;28 66-82
Copyright © 2008 by the American Association of Critical-Care Nurses
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